Pages

Monday, January 6, 2014

Today in the Washington Post, Ezra Klein analyzes the biggest
success of the Affordable Care Act – Medicaid – and how we are unfortunately not
hearing much about this programs success. Klein goes into an analysis of why he believes
that Democrats have not been trumpeting the expansion of Medicaid as much as
they should. He claims (and I agree) that Democrats are hesitant to sign
Medicaid’s praises because of America’s hesitancy towards expanding the social safety
net. Because “Obamacare” was sold as a program by which individuals who were
not able to purchase private health insurance (whether that be for pre-existing
conditions, the unaffordability of an individual plan, etc.) can now do so, one
wouldn't want to use as a support for the Affordable Care Act the expansion of
a government single-payer system. Further, because about half of the State have
refused to expand Medicaid, the success of the program is limited to certain
States (mostly Democratic ones).

This reluctance of Democrats and the Obama Administration to
emphasize the success of Medicaid is unfortunate, as something like that
program is actually where we should be headed as a country. Studies have shown
that Medicaid costs have not increased a substantial amount compared to private
insurance and Medicare and further studies have also shown that Medicaid is
more cost-effective on a per capita basis than private insurance. This makes
complete sense, because Medicaid, as a government program, has greater buying
power with healthcare providers than private insurance companies do. This difference
in buying power between government and private insurance companies is why
almost every other developed country that has a form of single-payer spends
less than the United States. Medicaid also has access to False Claims Act qui
tam suits for fraud, which private insurance companies do not have access to outside
of California and Illinois. These are just two of the reasons why Medicaid is more cost effective than private insurance.

Granted, many conservatives claim that there are fundamental
problems with Medicaid. For example, because the government is able to bargain
for lower payments, and because those payments are significantly lower than the
payments that doctors receive from private insurance plans, doctors are hesitant
to accept Medicaid patients. Because of this lack of access to a primary care
physician, that increases the usage by people on Medicaid of Emergency Rooms, as
the recently released Oregon study showed. But these critiques are deceiving,
because in reality the critique only works if you look at Medicaid as the
outsider in the “private insurance” market.
I could use the same data, look at it from a different angle ,and say
that it is not Medicaid that has the problem. Instead, I could just as legitimately
claim that it is the private insurance market which is the problem. It is
because the private insurance plans pay more than Medicaid that doctors will
not see Medicaid patients. It is because of private insurance plans that
Medicaid patients who cannot find a primary care physician use Emergency Rooms more.

Democrats need to up the ante. We need to emphasize to
America that compared to the rest of the world we DO have a substandard
healthcare system. Does it look great on the outside? Yes. We have gleaming new
operating rooms, state of the art equipment, and doctors paid out the wazoo.
But does that mean that we, as a society, get better care? No. In fact, other
countries spend substantially LESS on healthcare, and have better outcomes. Democrats
need to shout this from the rooftops; and we need to move to a form of single-payer.

The Supreme Court, in a unanimous decision, issued a stay of
Judge Shelby’s opinion striking down Utah’s Amendment 3 (gay marriage ban). As
much as members of the LGBT community are upset about this development, I’m not
at all surprised. I was actually more surprised that the 10th
Circuit didn't stay the decision itself.

Judge Shelby’s opinion, though good, enunciated a lot of
ideas that have either been rejected by many Courts (same-sex marriage bans are
discrimination on the basis of sex – which he really didn’t get too because he
found the ban failed rational basis review) or are pretty weak to begin with
(that same-sex couples have a “fundamental right to marry” – I don’t think that
we do based upon Due Process jurisprudence). The opinions strong points – the nature
of “responsible procreation” etc. – haven’t really had an opportunity to be
analyzed by Circuit Courts and in many cases such reasoning by the State has
been upheld by Courts around the United States. Granted, most of these unfavorable
opinions were issued prior to the landmark Supreme Court case of Windsor v.
United States, but I don’t personally see Windsor as a useful case to argue
against state same-sex marriage bans (given its very limited focus and
federalism issues). Therefore, because
the issues in Judge Shelby’s opinion were rather revolutionary in the Court
system, it SHOULD HAVE been stayed by the 10th Circuit. Granted, the
State of Utah botched the stay request, and its briefs to the 10th
Circuit were laughable, but that doesn't hide the fact that the Court should
have granted said stay.

Regardless, I want to take this opportunity to remind my
readers that the Supreme Court had an opportunity to deal with marriage
equality on a nationwide scale last year in the Prop 8 case. But they punted,
instead deciding to issue an opinion based on standing issues. Read into that
what you will (I have, and I read that Kennedy isn't ready to legalize marriage
nationwide), but that fact must be remembered.

So now what we have is a case being
appealed in the 10th Circuit (UT), one being appealed in the 9th
Circuit (NV), and many going to trial this month and next around the country.
2014 will be a fun year!